Marcia Frellick

February 26, 2016

BOSTON — Many rural regions in the United States are at risk for the kind of HIV epidemic that ripped through southeastern Indiana last year because of an increase in opioid addiction, said John Brooks, MD, a medical epidemiologist at the Centers for Disease Control and Prevention (CDC).

In January 2015, the Indiana State Department of Health began investigating 11 new HIV infections in Austin, a town of 4200 in Scott County. The connection between the cases appeared to be injection-drug use.

The county typically has fewer than five new HIV infections per year. As of February 1 this year, 188 people had been infected with HIV in Austin in less than 15 months, and 90% of them were coinfected with hepatitis C, Dr Brooks reported here at Conference on Retroviruses and Opportunistic Infections 2016.

Scott County is not unlike many other pockets in the United States, where access to care, awareness of risk, and education levels are low, and poverty, unemployment, and addiction rates are high, he said.

This outbreak gave insight into emerging new patterns of injection-drug use, said Harold Jaffe, MD, associate director for science at the CDC.

Our stereotype that this is a problem concentrated in the inner city involving primarily racial minority groups is no longer correct.

"Our stereotype that this is a problem concentrated in the inner city involving primarily racial minority groups is no longer correct," Dr Jaffe said. "This outbreak occurred in a very rural area, and it occurred entirely in whites and was related to the use of opioid pain medications. It's a problem across the United States."

During the epidemic, the drug of choice in Austin was oxymorphone, and even though the branded version of the drug has a coating designed to deter people from crushing it for injection, users — of all ages — found a way around that, Dr Brooks said.

Because the drug was so expensive — a tablet sold on the street was about $140 — users would inject the smallest amount possible to stave off withdrawal, which led to an average of 4 to 15 injections per day, he reported.

There was one part-time family doctor in the town, and the nearest HIV care center was at least a 45-minute drive. And most of the people infected with HIV didn't own cars.

A conservative estimate of the prevalence of HIV in Austin is 4.6%, said Dr Brooks.

"To put this into context, in the cities with the highest prevalence of HIV infection in the United States — San Francisco, New York City, and Miami — the current prevalence is between 0.8% and 1.0%," he pointed out.

Follow the Hepatitis C Virus

Acute hepatitis C surveillance and surveillance of other infections associated with injection-drug use, such as skin infections, is a great way to predict where the next HIV outbreak might occur, said Dr Brooks.

Such surveillance might have signaled the Indiana crisis, said Daniel Raymond, policy director for the Harm Reduction Coalition in New York City.

If you see a rise in hepatitis C, that's the time to start worrying that HIV may not be far behind.

"Indiana knew they had a hepatitis C problem linked to injection-drug use 2 years before the HIV outbreak," he told Medscape Medical News. "Because of the similar pathways of transmission — shared syringes — if you see a rise in hepatitis C, that's the time to start worrying that HIV may not be far behind."

Hepatitis C infections are rising in at least 30 states, and increases are "profound" in "places like Kentucky, West Virginia, and Tennessee," Raymond said.

Future prevention depends partly on making sure that people who are at risk know they are at risk, and that they know there is safe equipment if they intend to continue injecting drugs, Dr Brooks told Medscape Medical News.

Jurisdictions that have vulnerable patients should look at bringing testing to the places where concentrations of risky behavior are happening, such as prisons and substance-abuse treatment centers.

"We also recommend that they learn the landscape of services in their jurisdiction so that should an outbreak occur, they can immediately call to get help with treatment," he said.

Dealing With the Outbreak

One of the problems in dealing with the outbreak in Austin was that very few of the infected were employed or insured, and they lacked the documentation to enroll in the state-supported healthcare program, which had been expanded under Medicaid after the implementation of the Affordable Care Act.

The state responded by establishing a one-stop shop. People from the vital records department in the division of motor vehicles were brought in so that people could get a birth certificate or a driver's license and then enroll in insurance and get job training.

In addition, mistrust of law enforcement was a substantial issue in Austin, as it is in other places across the country.

"If you can get community leaders to speak to law enforcement leaders, and begin to move their hearts and minds, you can begin to help them understand that addiction is a medical illness," Dr Brooks said. "It is not a failure of a person or a crime in itself. When you can get them to see it as a medical illness, you can engage them in a public health response."

Dr Brooks, Dr Jaffee, and Mr Raymond have disclosed no relevant financial relationships.

Conference on Retroviruses and Opportunistic Infections (CROI) 2016: Abstract 132. Presented February 25, 2016.


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